Evaluation of the effectiveness of the chronic heart failure therapy using the device cardiac contractility modulation according to the new non-invasive method of the myocardium work analysis

Aim      To analyze echocardiographic parameters that reflect left ventricular (LV) myocardial contractility, using a novel method for evaluation of myocardial performance in patients with chronic heart failure (CHF) and atrial fibrillation (AF) during heart contractility modulation (HCM).

Material and methods  Standard echocardiographic parameters and indexes of myocardial strain and work were analyzed for 66 patients (52 men and 14 women; median age, 60 [54; 66] years). 36 patients had paroxysmal AF and 30 patients had permanent AF. All patients had CHF with a duration of 17 [4; 60] months; duration of AF was 12 [6; 36] months. At baseline, the left ventricular ejection fraction (LV EF) was 33 [27; 37] %.

Results After one year of HCM, LV EF significantly increased from 33 [27; 37] to 38 [33; 44] % (р=0.001). Also, there were improvements in the myocardial global longitudinal strain (from –6.00 [ – 8; – 4] to –8 [ – 10; – 6] %; р=0.001) and parameters of myocardial work, including the global work efficiency (from 74 [65; 79] to 80 [73; 87] mm Hg%; р=0.001), global constructive work (from 699 [516; 940] to 882 [714; 1242] mm Hg%; р=0.001), and global myocardial work index (from 460 [339; 723] to 668 [497; 943] mm Hg%; р=0.001). A segmentary analysis of LV work parameters showed positive changes in the myocardial constructive work in the area of the interventricular septal apical segment (at baseline, 844 [614; 1224]; after HCM, 1027 [800; 1520] mm Hg%; р=0.05) and the medium segment of the LV anteroseptal wall (at baseline, 593 [312; 1000]; after HCM, 877 [494; 1145] mm Hg%; р=0.05).

Conclusion      This method for analysis of the myocardial work provides a more detailed examination of LV structural and functional remodeling and mechanisms for its effects on the LV contractile function in patients with CHF. This method is promising and merits further study in various clinical situations.

1. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure// European Heart Journal (2021) 42, 35993726. doi:10.1093/eurheartj/ehab368.

2. James HMcGowan et al. Reliability of reporting left ventricular systolic function by echocardiography: A systematic review of 3 methods//American Heart Journal Volume 146, Issue 3, September 2003, Pages 388-39. doi: 10.1016/S0002-8703(03)00248-5.

3. Kraigher-Krainer E, Shah AM, Gupta DK, Santos A, Claggett B, Pieske B et. al; PARAMOUNT Investigators.J Am Coll Cardiol. Impaired systolic function by strain imaging in heart failure with preserved ejection fraction// J Am Coll Cardiol. 2014 Feb 11;63(5):447-56. doi: 10.1016/j.jacc.2013.09.052.

4. Park JJ, Park JB, Park JH, Cho GY. Global longitudinal strain to predict mortality in patients with acute heart failure// J Am Coll Cardiol 2018;71:1947–57. doi: 10.1016/j.jacc.2018.02.064.

5. Bálint Károly Lakatos аt al. Myocardial work index: a marker of left ventricular contractility in pressure-induced or volume overload-induced heart failure// ESC Heart Failure, 03.21 DOI:10.1002/ehf2.13314.

6. Chun-Li Wang at al. Incremental prognostic value of global myocardial work over ejection fraction and global longitudinal strain in patients with heart failure and reduced ejection fraction// Eur Heart J Cardiovasc Imaging. 2021 Feb 22;22(3):348-356. doi: 10.1093/ehjci/jeaa162.

7. Urheim S, Rabben SI, Skulstad H, Lyseggen E, Ihlen H, Smiseth OA. Regional myocardial work by strain Doppler echocardiography and LV pressure: a new method for quantifying myocardial function// Am J Physiol Heart Circ Physiol. 2005; 288:H2375–H2380. doi: 10.1152/ajpheart.00946.2004.

8. Russell K. et al. A novel clinical method for quantification of regional left ventricular pressure–strain loop area: a non-invasive index of myocardial work// European Heart Journal (2012) 33, 724–733. doi: 10.1093/eurheartj/ehs016.

9. Chan J., Shiino K., Obonyo N.G., Hanna J., Chamberlain R., Small A. Left ventricular global strain analysis by two-dimensional speckletracking echocardiography: the learning curve// J. Am. Soc. Echocardiogr. 2017; 30: 1081–90. doi: 10.1016/j.echo.2017.06.010.

10. Dawud Abawi at al. The non invasive assessment of myocardial work by pressure strain analysis: clinical applications// Heart Failure Reviews. doi: 10.1007/s10741-021-10119-4.

11. Butter C., Wellnhofer E., Schlegl M., Winbeck G., Fleck E., Sabbah H.N. Enhanced inotropic state of the failing left ventricle by cardiac contractility modulation elec- trical signals is not associatedwith increased myocardial oxygen consumption// J. Card. Fail. 2007; 13: 137–42. doi: 10.1016/j.cardfail.2006.11.004.

12. Petar M. Seferovic, Piotr Ponikowski , Stefan D .Anker et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology// Eur. J. Heart Fail. 2019 Oct; 21 (10): 1169–1186. doi: 10.1002/ejhf.1531.

13. Borggrefe MM, Lawo T, Butter C, et al. Randomized, double blind study of non-excitatory, cardiac contractility modulation electrical impulses for symptomatic heart failure// Eur. Heart J. 2008; 29 (8): 1019–28. doi: 10.1093/eurheartj/ehn020.

14. Manganaro R, Marchetta S, Dulgheru R, Ilardi F, Sugimoto T, RobinetS et al. Echocardiographic reference ranges for normal non-invasivemyocardial work indices: results from the EACVI NORRE study//European Heart Journal - Cardiovascular Imaging. 2019;20(5):582–90. doi: 10.1093/ehjci/jey188.

15. Jürgen Kuschyk, Susanne Roeger, RaphaelaSchneider , Florian Streitner, KsenijaStach , Boris Rudic et al. Efficacy and survival in patients with cardiac contractility modulation: Long-term single center experience in 81 patients.// International Journal of Cardiology. 2015;183:76–81. doi: 10.1016/j.ijcard.2014.12.178.

16. A. Kloppe, L. Boesche, A. Aweimer, A. Ewers , D. Schoene et al. Acute and short term safety and feasibility of the new OPTIMIZER SMART-system: Is it reasonable to avoid an atrial lead? EP Europace. 2018; 20(suppl_1):i48–i48. doi:10.1093/europace/euy015.128.

17. Galli E, Hubert A, Le Rolle V et al . Myocardial constructive work and cardiac mortality in resynchronization therapy candidates // Am Heart J. 2019 Jun;212:53-63. doi: 10.1016/j.ahj.2019.02.008.